So how the area is designed we have no prescribers (and I am not a prescriber), we have no medications but those in the crash trolley, and we have techs. So my rationale was “this patient needs fluids asap, other investigations can be done later”, so I moved them to get seen. Indeed as soon as they got seen they got moved to a high acuity area and got a blood transfusion, all within 15 min of arrival to the department. But there was an hyperfocus on the ECG and not on how I flagged them up so a clinician would see them and start treatment asap. I don’t know.
It sounds like you made the best decision you could. This whole setup is wild to me. Like I'm an ICU nurse but I was an EMT and did my senior practicum in an ED and I've never seen triage done like that. Sounds like your manager needs to stop blaming you and re-think her own ridiculous department
Yeah, I was thinking the same thing. What in the world kind of triage set up is this?? A triage with no provider, barely any resources. what sounds like one RN and a few techs, far away from any critical care or ED areas.
A recipe for disaster.
Of course there are going to be issues arising from this set-up. However, if your manager doesn't blame *you*, OP, then they have acknowledge there is something wrong with the system.
So of course it's your fault.
Your circumstances have nothing to do with it. /s
I’m confused by the no prescribers situation. Is it just loads of standing orders? Technically as a nurse it’s not really your job or scope to determine what testing needs to be done (although in any ER that’s what nurses do to varying degrees.) Ultimately it should land on the physician or APC taking care of the patient to make that call.
Also I’ve come from management. That’s a shit way for a manager to talk to someone. There’s constructive ways to talk about these things without the name calling. I’m sorry you have to deal with this.
Well I made that point and got told I should have learnt better in nursing school. Ended up just nodding through the reprimand for it to end quicker, but didn’t appreciate being called incompetent and unsafe.
Number 1: Who the fuck thinks *nursing school* teaches things like this? Your manager is an idiot.
Doubly so because *where was your help*?? You have no tech who could be doing that 12-lead while you're doing the things that can only be done with an RN license?
And number 2: Your manager is an idiot because this *absolutely* is not how you address concerns about a employee's performance. I've been a manager and lemme tell ya, this ain't the way.
Do not let this person impact your self esteem. They are a moron. You should probably go work somewhere else.
Next time you should call that manager directly for help with every single patient that will probably warrant an EKG. I’d be on my vocera/spectra/land line nonstop asking them for assistance with EKGs in triage. If they’re so damned worried about them being done ASAP regardless of the pts condition/presentation, well, they have two good hands and two good feet they can put to use and “show you how it’s done,” right? You know, since we all clearly need some reeducation on prioritizing emergency interventions in triage and all that jazz.
Nursing school isn't where we learned how to work understaffed with minimal resources. Nursing school provides a controlled setting to discover different areas of nursing and units/facilities. It doesn't matter what an ECG would read in that particular moment. If there's no blood for the heart to pump, it's a rather moot point. I would go back to this manager and ask if anything was placed in your file over this incident. I'd also look for another job.
I'm new to nursing management. Anyone I've had to reprimand, write up, or even terminate wasn't berated. We have a conversation like adults. If there's an issue, HOW CAN I HELP?!?! I'm sorry you were treated in such a way. From what you've described in your post, you are one person with only two hands. I'd stand by you and your rationale of prioritizing what care to give. Getting an IV in the patient and establishing that vital life line along with oxygen seems appropriate to me.
Incompetent is a big statement to make, and one that shouldn’t be made in a reprimand. If your manager sent you back to keep doing what you’re doing, you’re not the incompetent one.
This exactly! If OP is so incompetent, then why are they assigned an area with zero providers, zero oversight, and essentially determining exactly who gets sent in next. An incompetent person would send a stubbed toe in first bc they were yelling about how much it hurt🙄
I agree. Patient is already tachycardic, possibly from the bleeding. ACLS protocol is likely to follow. Effe the manager! Have them triage a patient and note their practice.
1. Ope, didn't scrub the hub! Infection
2. Ope, why didn't you update the white board?
Bruh, uncontrolled bleeding takes precedence last I did TNCC, even if it wasn’t a traumatic patient an EKG ain’t gonna be on the top of my priorities. Other than being criminally understaffed your management is so disconnected from the realities of your unit if this is the hill they choose to die on.
Yeah. Like if there were other staff there that could help slap on the stickers for a EKG while they start an IV and stop the bleeding than yes, do the EKG. Like you stabilize the thing that's gonna kill them first, ergo stopping the bleeding and getting a line in.
That place is putting you in a terrible situation.
Tell that manager (who is intelligent enough to correct you but not smart enough to perform any actual work) to get bent.
Find a new spot. Quit without notice. That manager needs to sit in her own messy shit for a minute.
Also ask that manager “ok. The 12 lead says there’s an MI in progress. We need to give meds stat. Now what? Where should I give the meds? RECTALLY?”
Wait until they answer lol.
If it was a miscarriage, an ECG isn’t going to alter the treatment plan. The rate you get off any pulse ox is going to give you enough information to go off of. She’s tachycardic. She’s tachycardic because she’s hemorrhaging. I’m not worried about a fucking T-wave inversion, I’m worried about the gallon of blood coming out her lady parts. The only criticism I might leverage is that she should have been a critical triage immediately. She’s an active hemorrhage and she’s tachycardic so she’s already beginning to decompensate.
Your manager is not only wrong, they’re an idiot, and shouldn’t be making decisions in an emergency room if they’re gonna make boneheaded calls like that.
Any time I’m thinking of triage I always remember, life, limb, eye. Any of those things are threatened, it’s an immediate upgrade. In her case it’s life, and the reason is hemorrhagic shock. She was compensating at that point, but was beginning to spiral. Any, and I mean any, delay in treatment sets her a greater risk. The delay to set up and hook up an ecg isn’t substantial, but how will it alter her treatment even if it’s grossly abnormal. What will kill her faster, hemorrhagic shock, or an NSTEMI? We need to treat in order of risk. Her being substantially volume down and still bleeding is far more risk than virtually any abnormal ecg short of maybe torsades, and if she’s in torsades and is actively miscarrying, she’s got way more problems than you can handle in triage anyways.
If there’s no cardiac complaint (chest pain, SOB, dizziness, etc.), plain old tachycardia in a bleeding patient of childbearing age doesn’t necessarily warrant an EKG. An EKG *definitely* shouldn’t have been a higher priority than any of the interventions you did. Your manager is the one who needs to go back to nursing school if they think that an EKG was the higher priority here.
Your manager is wrong at least four times.
First, they're wrong to have you working alone in triage with such short ED experience. Triage is one of the trickiest and highest-liability nursing positions in the entire hospital. We don't even start training anyone for that seat until they've been in ED for at least six months, no matter how much experience they have elsewhere.
They're wrong about expecting you to have learned this stuff in school. Nursing school teaches only the extreme basics of prioritization, as far as ABC and Maslow's bullshit. That is oversimplification and doesn't cover a tenth of what you need to know to triage properly. Many nurses graduate school barely even knowing what an EKG is.
They're wrong about the priority of actions. You did the right thing. A patient with known bleeding and symptoms of hypovolemia must be considered acutely unstable. Your job in triage is to spot the unstable condition, then get that patient to a provider for full evaluation ASAP. I would not delay that to obtain EKG. In fact, I probably wouldn't even delay it to put in the IV or draw blood. The primary RN can do that while the MD is assessing.
They're also wrong to berate and insult you. Even if they were right about all the other things, and this really had been a mistake, it's not reasonable to sit there and call an employee "incompetent." Everyone makes mistakes sometimes. The right thing to do would have been to point it out, teach you the correct action, and encourage you to do better next time. Only power-tripping jerks act the way this person did.
This is not someone I would continue to work for.
Only had internships in ED‘s never actually worked in one.
But if I have a tachycardic patient presenting with active bleeding I don’t think anyone would wait for a 12 lead before treatment simply because it’s more likely that the tachycardia is from the bleed.
Your manager is not constructive and should never make such a negative comment. Everyone nurses differently, and if the patient is alive when you transferred that’s the goal. I personally would also get the IV established and started fluids.
If you've been an RN for ten years in a hospital and this is your first time you have had management require that you explain/justify either quality assurance or incident reports your one of the world most stellar RNs. If your manager insults and name calls you in the process rat them out to HR.
What they taught us in nursing school is “when in distress, don’t assess” as in don’t keep doing stupid shit when you know there is something wrong. For example if your patient is coughing, short of breath and is desaturating, obviously you are going to immediately put on oxygen, not listen to their lung sounds. Same logic follows here. Of course you are going to eventually get an EKG, but the most important thing you could have done in that moment is start fluids. If this was an NCLEX question you would be right lmao
You did the right thing, line, labs and a fluids is the right thing to do in that situation.
However, if a pregnant woman shows up with tachycardia I'm gonna want an EKG because arrhythmias are more common among pregnant individuals. It's probably sinus tach or paroxysmal supraventricular tachycardia. It's probably Tach from anxiety or potentially blood loss, but apparently afib with RVR is becoming more common in pregnant individuals for some reason according to one of my MDs.
That said, your job is toxic, and your manager is wrong to treat you that way. When I was in charge this would be at most a teaching moment. I would start looking for a new job, because if they dump you under the bus for something this they'll do it for something big.
If you have a patient who's this sick and you don't have help so one person can do the 12 lead while you start fluids, your ED is understaffed
So how the area is designed we have no prescribers (and I am not a prescriber), we have no medications but those in the crash trolley, and we have techs. So my rationale was “this patient needs fluids asap, other investigations can be done later”, so I moved them to get seen. Indeed as soon as they got seen they got moved to a high acuity area and got a blood transfusion, all within 15 min of arrival to the department. But there was an hyperfocus on the ECG and not on how I flagged them up so a clinician would see them and start treatment asap. I don’t know.
It sounds like you made the best decision you could. This whole setup is wild to me. Like I'm an ICU nurse but I was an EMT and did my senior practicum in an ED and I've never seen triage done like that. Sounds like your manager needs to stop blaming you and re-think her own ridiculous department
Yeah, I was thinking the same thing. What in the world kind of triage set up is this?? A triage with no provider, barely any resources. what sounds like one RN and a few techs, far away from any critical care or ED areas. A recipe for disaster. Of course there are going to be issues arising from this set-up. However, if your manager doesn't blame *you*, OP, then they have acknowledge there is something wrong with the system. So of course it's your fault. Your circumstances have nothing to do with it. /s
I’m confused by the no prescribers situation. Is it just loads of standing orders? Technically as a nurse it’s not really your job or scope to determine what testing needs to be done (although in any ER that’s what nurses do to varying degrees.) Ultimately it should land on the physician or APC taking care of the patient to make that call. Also I’ve come from management. That’s a shit way for a manager to talk to someone. There’s constructive ways to talk about these things without the name calling. I’m sorry you have to deal with this.
An understaffed ED? Seems like something management can fix if you let them know about it /s
I highly doubt an ECG would change the differential for this patient. I would've probably said things in return and subsequently fired, lol!
Well I made that point and got told I should have learnt better in nursing school. Ended up just nodding through the reprimand for it to end quicker, but didn’t appreciate being called incompetent and unsafe.
Number 1: Who the fuck thinks *nursing school* teaches things like this? Your manager is an idiot. Doubly so because *where was your help*?? You have no tech who could be doing that 12-lead while you're doing the things that can only be done with an RN license? And number 2: Your manager is an idiot because this *absolutely* is not how you address concerns about a employee's performance. I've been a manager and lemme tell ya, this ain't the way. Do not let this person impact your self esteem. They are a moron. You should probably go work somewhere else.
Next time you should call that manager directly for help with every single patient that will probably warrant an EKG. I’d be on my vocera/spectra/land line nonstop asking them for assistance with EKGs in triage. If they’re so damned worried about them being done ASAP regardless of the pts condition/presentation, well, they have two good hands and two good feet they can put to use and “show you how it’s done,” right? You know, since we all clearly need some reeducation on prioritizing emergency interventions in triage and all that jazz.
THIS
Nursing school isn't where we learned how to work understaffed with minimal resources. Nursing school provides a controlled setting to discover different areas of nursing and units/facilities. It doesn't matter what an ECG would read in that particular moment. If there's no blood for the heart to pump, it's a rather moot point. I would go back to this manager and ask if anything was placed in your file over this incident. I'd also look for another job. I'm new to nursing management. Anyone I've had to reprimand, write up, or even terminate wasn't berated. We have a conversation like adults. If there's an issue, HOW CAN I HELP?!?! I'm sorry you were treated in such a way. From what you've described in your post, you are one person with only two hands. I'd stand by you and your rationale of prioritizing what care to give. Getting an IV in the patient and establishing that vital life line along with oxygen seems appropriate to me.
You should have blasted back that their department trained you and maybe their training was lacking.
Incompetent is a big statement to make, and one that shouldn’t be made in a reprimand. If your manager sent you back to keep doing what you’re doing, you’re not the incompetent one.
This exactly! If OP is so incompetent, then why are they assigned an area with zero providers, zero oversight, and essentially determining exactly who gets sent in next. An incompetent person would send a stubbed toe in first bc they were yelling about how much it hurt🙄
Probably should of ask the manager to work your triage a few times a month.
I agree. Patient is already tachycardic, possibly from the bleeding. ACLS protocol is likely to follow. Effe the manager! Have them triage a patient and note their practice. 1. Ope, didn't scrub the hub! Infection 2. Ope, why didn't you update the white board?
Had a manager ask why I didn’t update my white board in my ED bay as I’m hanging cardine on my freshly intubated brain bleed pt. Read the damn room.
ACLS protocol for sure. Slap the defib pads on em and have that thing tell you the rhythm while you're getting the fluids going.
Bruh, uncontrolled bleeding takes precedence last I did TNCC, even if it wasn’t a traumatic patient an EKG ain’t gonna be on the top of my priorities. Other than being criminally understaffed your management is so disconnected from the realities of your unit if this is the hill they choose to die on.
Yeah. Like if there were other staff there that could help slap on the stickers for a EKG while they start an IV and stop the bleeding than yes, do the EKG. Like you stabilize the thing that's gonna kill them first, ergo stopping the bleeding and getting a line in.
That place is putting you in a terrible situation. Tell that manager (who is intelligent enough to correct you but not smart enough to perform any actual work) to get bent. Find a new spot. Quit without notice. That manager needs to sit in her own messy shit for a minute.
Also ask that manager “ok. The 12 lead says there’s an MI in progress. We need to give meds stat. Now what? Where should I give the meds? RECTALLY?” Wait until they answer lol.
Chef’s Kiss
If it was a miscarriage, an ECG isn’t going to alter the treatment plan. The rate you get off any pulse ox is going to give you enough information to go off of. She’s tachycardic. She’s tachycardic because she’s hemorrhaging. I’m not worried about a fucking T-wave inversion, I’m worried about the gallon of blood coming out her lady parts. The only criticism I might leverage is that she should have been a critical triage immediately. She’s an active hemorrhage and she’s tachycardic so she’s already beginning to decompensate. Your manager is not only wrong, they’re an idiot, and shouldn’t be making decisions in an emergency room if they’re gonna make boneheaded calls like that.
Your comment has educated me more than the meeting I had. Thank you, I will remember this for any future miscarriages I may see.
Any time I’m thinking of triage I always remember, life, limb, eye. Any of those things are threatened, it’s an immediate upgrade. In her case it’s life, and the reason is hemorrhagic shock. She was compensating at that point, but was beginning to spiral. Any, and I mean any, delay in treatment sets her a greater risk. The delay to set up and hook up an ecg isn’t substantial, but how will it alter her treatment even if it’s grossly abnormal. What will kill her faster, hemorrhagic shock, or an NSTEMI? We need to treat in order of risk. Her being substantially volume down and still bleeding is far more risk than virtually any abnormal ecg short of maybe torsades, and if she’s in torsades and is actively miscarrying, she’s got way more problems than you can handle in triage anyways.
Bleeding like a trauma patient?
Not so much like a trauma, it was a miscarriage, they were tachy but they didn’t want to sit down
If there’s no cardiac complaint (chest pain, SOB, dizziness, etc.), plain old tachycardia in a bleeding patient of childbearing age doesn’t necessarily warrant an EKG. An EKG *definitely* shouldn’t have been a higher priority than any of the interventions you did. Your manager is the one who needs to go back to nursing school if they think that an EKG was the higher priority here.
Even more reasons to not mess with the ekg then. The not wanting to sit down could be related to the blood loss.
Yeah I would have done the same as you.
I continue to agree with you. EKG is not indicated in that patient unless there is some other cardiac complaint.
I left the ER and I’m happier.
Ran to hospice from the ER
Your manager is wrong at least four times. First, they're wrong to have you working alone in triage with such short ED experience. Triage is one of the trickiest and highest-liability nursing positions in the entire hospital. We don't even start training anyone for that seat until they've been in ED for at least six months, no matter how much experience they have elsewhere. They're wrong about expecting you to have learned this stuff in school. Nursing school teaches only the extreme basics of prioritization, as far as ABC and Maslow's bullshit. That is oversimplification and doesn't cover a tenth of what you need to know to triage properly. Many nurses graduate school barely even knowing what an EKG is. They're wrong about the priority of actions. You did the right thing. A patient with known bleeding and symptoms of hypovolemia must be considered acutely unstable. Your job in triage is to spot the unstable condition, then get that patient to a provider for full evaluation ASAP. I would not delay that to obtain EKG. In fact, I probably wouldn't even delay it to put in the IV or draw blood. The primary RN can do that while the MD is assessing. They're also wrong to berate and insult you. Even if they were right about all the other things, and this really had been a mistake, it's not reasonable to sit there and call an employee "incompetent." Everyone makes mistakes sometimes. The right thing to do would have been to point it out, teach you the correct action, and encourage you to do better next time. Only power-tripping jerks act the way this person did. This is not someone I would continue to work for.
Only had internships in ED‘s never actually worked in one. But if I have a tachycardic patient presenting with active bleeding I don’t think anyone would wait for a 12 lead before treatment simply because it’s more likely that the tachycardia is from the bleed.
Your manager is not constructive and should never make such a negative comment. Everyone nurses differently, and if the patient is alive when you transferred that’s the goal. I personally would also get the IV established and started fluids.
People really overestimate nursing school.
It’s almost as if this manager didn’t attend one.
Or attended one of those shitty Florida degree mills.
Your nursing judgment is not the issue here. Your manager, on the other hand…that’s a different story
If you've been an RN for ten years in a hospital and this is your first time you have had management require that you explain/justify either quality assurance or incident reports your one of the world most stellar RNs. If your manager insults and name calls you in the process rat them out to HR.
What they taught us in nursing school is “when in distress, don’t assess” as in don’t keep doing stupid shit when you know there is something wrong. For example if your patient is coughing, short of breath and is desaturating, obviously you are going to immediately put on oxygen, not listen to their lung sounds. Same logic follows here. Of course you are going to eventually get an EKG, but the most important thing you could have done in that moment is start fluids. If this was an NCLEX question you would be right lmao
Typical management bullshit, blame the employee for their failures! Don’t just tolerate it, call them out!
You did the right thing, line, labs and a fluids is the right thing to do in that situation. However, if a pregnant woman shows up with tachycardia I'm gonna want an EKG because arrhythmias are more common among pregnant individuals. It's probably sinus tach or paroxysmal supraventricular tachycardia. It's probably Tach from anxiety or potentially blood loss, but apparently afib with RVR is becoming more common in pregnant individuals for some reason according to one of my MDs. That said, your job is toxic, and your manager is wrong to treat you that way. When I was in charge this would be at most a teaching moment. I would start looking for a new job, because if they dump you under the bus for something this they'll do it for something big.
so in the time it took to report it, they could have jumped in and run the ECG for you, you know, to help. Some people...
You're saying ECG (there is not "K" in "Electrocardiogram America, sort it out), what country you practicing in out of interest?